To evaluate efficacy and outcome of embolisation following pelvic ring injuries in patients presented with ongoing hypovolaemic shock.

Between 2000 and 2003, 200 poly-trauma patients presented in our institutions following pelvic ring injuries. Those with ongoing hypovolaemic shock who were treated within 24h of admission with embolisation were included in this study. Demographics, mechanism of injury, ISS, type of pelvic ring fracture, arterial source of bleeding, hours from injury to embolisation, and outcome were all recorded prospectively. Out of the 200 treated in our institutions 17 (8.5%) underwent angio-embolisation. The mean age of the patients was 37 (14-70) and the mean ISS was 29. Distribution of pelvic ring injuries included: 3LC, 7APC, 7VS. The mean time from injury to embolisation was 15 hours. 8/17 patients were initially treated with an external fixator.

The distribution of arterial injuries was: 7 superior gluteal arteries, 8 internal iliac arteries, 1 obturator artery and 1 internal pudental artery. The mean number of units transfused prior to embolisation was 22 (range 6-50). Mortality rate was 4 (23%) out of 17 embolised patients. Angio-embolisation for pelvic ring injuries occurred in 8.5% of our study population.

This study indicates that only a small proportion of patients required embolisation secondary to arterial bleeding. The overall survival rate was in accordance to published international experience. Embolisation should be considered as a valid adjunct in some selected group of patients with pelvic fractures where ongoing bleeding refractory to other treatment modalities is present.

Purpose: To evaluate efficacy and outcome of embolisation following pelvic ring injuries in patients presented with ongoing hypovolaemic shock.

Methods: Between 2000 and 2003, 200 poly-trauma patients presented in our institutions following pelvic ring injuries. Those with ongoing hypovolaemic shock who were treated within 24h of admission with embolisation were included in this study. Demographics, mechanism of injury, ISS, type of pelvic ring fracture, arterial source of bleeding, hours from injury to embolisation, and outcome were all recorded prospectively.

Results: Out of the 200 treated in our institutions 17 (8.5%) underwent angio-embolisation. The mean age of the patients was 37 (14–70) and the mean ISS was 29. Distribution of pelvic ring injuries included: 3LC, 7APC, and 7VS. The mean time from injury to embolisation was 15 hours. 8/17 patients were initially treated with an external fixator. The distribution of arterial injuries was: 7 superior gluteal arteries, 8 internal iliac arteries, 1 obturator artery and 1 internal pudental artery. The mean number of units transfused prior to embolisation was 22 (range 6–50). Mortality rate was 4 (23%) out of 17 embolised patients. Angio-embolisation for pelvic ring injuries occurred in 8.5% of our study population. This study indicates that only a small proportion of patients required embolisation secondary to arterial bleeding. The overall survival rate was in accordance to published international experience.

Conclusion and Significance: Embolisation should be considered as a valid adjunct in some selected group of patients with pelvic fractures where ongoing bleeding refractory to other treatment modalities is present.

Introduction: Adult acquired flat foot deformity is recognised as a spectrum of pathology related to tibialis posterior dysfunction (TPD) and plantar ligament insufficiency. Cobb has described a method of reconstruction in pure Johnson and Strom type II TPD using a split Tibialis Anterior musculo-tendinous graft.

Methods: We describe a prospective study of 32 patients treated by the Cobb technique and a medial displacement translational os calcis osteotomy for Johnson and Strom type II TPD. There were 28 females and four males (age range 44–66, average 54) each with unilateral disease. The average follow up was 5.1 years, range 3 to 7.2 years. Each patient had failed conservative management and the staging was confirmed clinically and radiologically (ultrasound scanning and MRI). The surgery was performed as described by Cobb but with a bone tunnel in the navicular rather than the medial cuneiform. Postoperative immobilisation in plaster was for eight weeks followed by orthotics and physiotherapy.

Results: All the os calcis osteotomies healed uneventfully. 29 of the 32 patients were able to perform a single heel rise test (none prior to surgery) at twelve months follow-up. These patients had grade 5 power of the tibialis posterior tendon. The others had grade 4 power and were also happy with the result. The mean American orthopaedic foot and ankle society (AOFAS) hindfoot score was 82. There was one superficial wound infection successfully treated by antibiotics and a temporary dysaesthesia in the medial plantar nerve in another.

Discussion: This prospective study confirms that the Cobb technique is an excellent method of treating pure Johnson and Strom type II TPD after failed conservative management. The procedure is performed with a medial displacement os calcis osteotomy but in selected cases may be combined with spring ligament repair and lateral column lengthening. An updated classification will be presented designed to facilitate the decision making process in this difficult condition.

Introduction: Osteoporosis, a major public health burden, is associated with increased fracture risk. Fracture healing in osteoporosis is altered with reduced callus formation and impaired biomechanical properties of newly formed bone leading to high risk of fixation failure. Experimental data have shown decreased healing potential in aged animals and in animal models of post-menopausal bone loss. It is unclear whether fracture healing is similarly impaired in senile osteoporosis. The objective of this study is to investigate fracture healing in a small animal model of senile osteoporosis, senescence-accelerated mouse prone 6 (SAMP6).

Materials & Methods: A mid-femur osteotomy was created in SAMP6-mice (n=24) and senescence-resistant inbred strains (SAMR1) (n=24) were used as controls. The osteotomy was rigidly fixed using a newly developed screw-plate-implant (MouseFix). Fracture healing was evaluated at 7, 14, 28 and 42 days after surgery using micro-CT and histomorphometry. Biochemical marker for bone formation (osteocalcin) and bone resorption (TRAP5b) were evaluated from serum samples. MSC were extracted from the femurs of mice and cultured in vitro and differentiated into either osteoblasts or adipocytes using standard induction media.

Results: Studies carried out in vitro confirmed that MSC isolated from the bone marrow of SAMP6 mice had a reduced tendency to differentiate toward the osteoblast cell lineage as previously reported in human osteoporotic patients. Although osteoblastogenesis was clearly impaired, the formation of new bone in SAMP6 mice was comparable to that observed in SAMR1 mice. Similar results were found for histomorphometry data analyzing the degree of bone mineralisation. Interestingly, osteocalcin levels were significantly increased in serum samples from osteoporotic mice at day 7 and 14 following fracture.

Discussion: The data presented here indicates that fracture healing proceeds normally in a mouse model for senile osteoporosis. This finding supports the clinical observation that although fracture fixation is difficult in osteoporosis, healing potential seems to be unchanged. MSC from osteoporotic patients as wells as from SAMP6-mice show reduced proliferation rate together with adipogenic rather than osteogenic differentiation pattern. However, decreased cell dynamics seems not to influence diaphyseal fracture healing. Other sources of MSC other than bone marrow-derived MSC may therefore be pivotal in determining the outcome of intramembranous bone repair in both normal and osteoporotic bone.

Statement of Purpose: We tested the null hypothesis of no significant difference in arthroscopy rates for patients on a waiting list for arthroscopy in patients in which surgeons had a knee magnetic resonance imaging scan report prior to surgery, compared to those who did not have a report.

Methods and Results: This is a single-centre randomised controlled trial. 252 eligible patients consented and randomised. The two groups were similar with respect to a range of baseline factors. Very few arthroscopies were not performed–4.8% in the intervention arm and 5.5% in the control arm (χ2=0.06, df=1, p> 0.05). A longitudinal analysis of the secondary outcomes showed that there were no significant differences between the intervention and the control arms of the study.

Conclusion: Magnetic resonance imaging, prior to knee arthroscopy, does not lead to a reduction in the number of arthroscopies undertaken in the intervention group nor improve patient outcome in a range of secondary measures.

Statement of Purpose: We tested the null hypothesis of no significant difference in arthroscopy rates for patients on a waiting list for arthroscopy in patients in which surgeons had a knee magnetic resonance imaging scan report prior to surgery, compared to those who did not have a report.

Methods and Results: This is a single-centre randomised controlled trial. 252 eligible patients consented and randomised. The two groups were similar with respect to a range of baseline factors. Very few arthroscopies were not performed −4.8% in the intervention arm and 5.5% in the control arm (χ²=0.06, df=1, p> 0.05). A longitudinal analysis of the secondary outcomes showed that there were no significant differences between the intervention and the control arms of the study.

Conclusion: Magnetic resonance imaging, prior to knee arthroscopy, does not lead to a reduction in the number of arthroscopies undertaken in the intervention group nor improve patient outcome in a range of secondary measures.

Residual pain after total hip due to a number of causes both local to and replacement may be distant from the hip. We describe pain related to the psoas muscle after total hip replacement in nine patients. All presented with characteristic symptoms. We describe the key features and management. Gratifying results were achieved with treatment. This diagnosis should be considered when assessing patients with pain after total hip replacement.

The aim of this study was to assess the accuracy of pedicle screw placement using NAVITRAK, a system of Computer Assisted Orthopaedic Surgery and conventional fluoroscopic technique.

Twelve porcine lumbar spines were scanned pre-operatively by computer tomography for 3-D reconstruction ( 1 mm slice thickness, 1mm increment and 2.5 mm pitch ).

Computer randomisation divided the specimens between surgeons of different experience, and the two pedicles of each vertebral level between the two surgical techniques. Stainless steel screws (6.5 spongiosa) were inserted.

Post-operatively, fluoroscopic- and CT imaging were blindly assessed for accuracy by two independent observers, and compared to macroscopic dissection of the spinal segments.

Of 168 pedicles in 12 porcine specimens, 166 received a pedicle screw. Two pedicle screw placements were abandoned. Sixyty-one screws (73%) were placed satisfactorily with the CAOS system, 56 (67.5%) in the conventional group.

In 26 pedicles the screws were placed unsatisfactorily (12 pedicles (46.2%) with the NAVITRAK system and 14 pedicles (53.8%) with the conventional technique.

The NAVITRAK system in combination with stainless steel screws showed a difference of 5.5% in misplacement in favour for the computer assisted technique.

The aim of this study was to assess the accuracy of pedicle screw placement comparing Computer Assisted Orthopaedic Surgery equipment with conventional fluoroscopic technique.

Twelve porcine cervical spines were scanned pre-operatively by computer tomography for 3D reconstruction (1 mm slice thickness, 1mm increment and 1 mm pitch).

Computerised randomisation divided the specimens between surgeons of different experience, and the two pedicles of each vertebral level between the two surgical techniques. Stainless steel screws (6.5 diameter, spongiosa) were inserted. Post-operatively, fluoroscopic imaging was used for accuracy assessment by two independent observers, and findings were compared to macroscopic dissection of the spinal segments.

Of 96 pedicles in 12 porcine specimens, 78 received a pedicle screw, 18 screw placements were abandoned, 38 (39.6%) were satisfactorily placed (19 in each, p> 0.05). 40 screws were misplaced, 18 (45%) with the NAVITRAK system vs. 22 (55%) with the conventional technique. These single factor results (all non-significant), were corroborated using a linear logistic regression model. Some heterogeneity in performance was detected between surgeons, independently of the type of technique used.

Computer assisted surgery is an aiming device and is not advantageous over conventional methods in spines with high bone density.